UCR 068: FAQs - questions from the online communities and group

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UCR 068: FAQs; Staged Procedure, IPP codes, Chordee/Hypospadias codes; QW;

September 21, 2021

Mark and Scott discuss questions from the Urology Coding and Reimbursement Group

Question 1 (:55)

I received a denial from local HMO insurance company for 52310-58 stating the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
The patient on 8/11 had an obstructing ureteral stone and was stented pushing the stone back into the kidney billed 52330 and 52332.
On 8/19 the patient had ESWL billed 50590.
8/24 billed 52310-58 in office.
I contacted the insurance company and this was their response.
After reviewing all the claims it appears that claim for DOS 8/24/21 processed correctly as billed. In order for a claim to pay during the global period it must be separate and identifiable from the global service, and billed with the appropriate modifier showing it is separate and identifiable. The documentation submitted must also show it is not related to the global procedure performed. The providers office should be utilizing the appropriate modifiers during a global period showing it is a distinct procedural service. This information is also available on the CMS website. CMS also details which modifier to utilize for reporting removal of multiple stones.
Any suggestions on how to proceed?
Thank you
Joan

Question 2 (9:20)

A) Please help me code this! Patient already had the procedure and there is a pending auth. that won't be approved until I send them the code(s). Thanks!!!
Revision of IPP including cystotomy removal & replacement of IPP Reservoir.

b) How do I code this scenario?
IPP Reservoir eroded into patient's bladder, Dr. Removes the foreign body in the bladder and replaces the 1 component of the IPP. Any help would be greatly appreciated!!! Thanks! Ethel

Question 3 (14:30)

For Pediatric Urology practice, what is the difference between CPT codes 54300 and 54304 as the allowed dx codes are the same for both and the service is for chordee, not hypospadias. Thank you!

Question 4 (17:55)

I have a question about the QW modifier. We are billing 85014 which is on the CMS CLIA waived test list. Should we only bill 85014 with the QW to Medicare or does this apply to commercial insurances too?

Question 5 (19:25)

We recently started drawing blood to send for BRAC analysis testing for our Prostate Cancer patients. I'm thinking the CPT code to use is 36415 but when I look on the CMS website there is no fee and the status is X.
Can we bill a nurse visit for this and is there a DX code besides C61, prostate cancer, that we should be using for the blood draw? It may not be a lot of money but we are buying the supplies and taking up a nurse's time to do this, shouldn't we be reimbursed?

Thank you,
Joanna